My Deployment to Haiti: An ED Nurse's Experience

Newswise — On Tuesday, January 12, 2010, at 4:53 p.m., a 7.0 magnitude earthquake struck Haiti outside the capital of Port-au-Prince. This was the country’s most severe earthquake in 200 years with a death toll that is estimated to reach 200,000. Widespread destruction resulted from the quake and the capital city was devastated.

Haiti, which is about the size of Maryland, is a nation in the West Indies that occupies the western one-third of the island Hispaniola. By most economic measures, Haiti is the poorest country in the Americas and the least developed. Nearly 80 percent of the population is estimated to be living in poverty, and most Haitians live on two dollars per day or less.

Unfortunately, 90 percent of Haitian children suffer from waterborne diseases and intestinal parasites. Even before the earthquake, according to the World Health Organization (WHO), nearly one half of the causes of death were from HIV/AIDS, respiratory infections, meningitis and diarrheal diseases (including cholera and typhoid). Nearly five percent of Haiti’s adult population is infected with HIV. Haiti’s healthcare system was already broken before the tragedy.

Haiti has few roads in good condition. Even secondary roads and bridges are nearly impassable and difficult to travel. Healthcare services were already limited, and rescue and relief efforts are hindered further due to the increased lack of infrastructure.

Despite these issues, Haiti’s major strength is its people. It was the first independent nation in Latin America and the first black-led republic in the world. The sincerity and strong will of its people are seen in their willingness to fight to survive and help each other. This was displayed not only in the adults, but also in the children. For example, a four-year old girl had her right foot amputated and endured the hardship without any family. During recovery, she slept on the floor of our treatment tent with an eight-year-old girl with a lower leg external fixator in place. The eight-year-old gave love and comfort to a little girl she didn’t even know despite dealing with her own injuries.

On January 25, 2010, I was deployed to Port-au-Prince, Haiti, and assigned to Haitian Group for the Study of Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO) Tent Hospital there. I am a member of Missouri One Disaster Medical Assistance Team (MO-1 DMAT). DMATs operate within the National Disaster Medical System (NDMS) and were created in 1983 to address the need for a coordinated response from the nation’s healthcare system during disasters that overwhelmed an area’s healthcare infrastructure. There are approximately 50 teams in the U.S. comprised of physicians, nurse practitioners, physician assistants, registered nurses, medics, respiratory therapists, pharmacists, mental health workers, communication specialists and logistics experts. We were making history since this was the first time for NDMS to send teams internationally.

MO-1 DMAT’s 35-member team left Lambert-St. Louis International Airport early Saturday morning, January 23. We arrived in Atlanta, Georgia as our staging area. This would be the last area of comfort that we would experience for the next two weeks. During our brief stay in Atlanta, we completed fit testing, and received the necessary vaccines and medications to prevent malaria. We left for Haiti at 2 a.m. Monday morning on a private jet. No one knew what to expect.

We arrived at the Port-au-Prince airport to a bright, sunny day with extreme humidity. Troops and supplies were all over the tarmac. We stayed at the airport for several hours waiting for transportation. Once our rides arrived, we loaded our luggage and crammed ourselves into an older model, non-air conditioned bus. Our security, provided by the 82nd Airborne, warned us to be prepared to see casualties along the road and that some smells may be intense. Many sights were difficult to handle emotionally. We were very blessed to have Chaplain Jim with us from Iowa-1 DMAT. He was truly our savior. He helped us see the best in every situation throughout the next two weeks and even helped with patient care.

Once we arrived at GHESKIO, we were greeted by the International Medical Surgical Response Team (IMSuRT) East staff. Our tent hospital was the most sophisticated hospital in operation on the island. It consisted of an operating suite, six to eight ICU beds, a major tent, a minor tent, a procedure tent, pediatric treatment area, isolation for several TB patients and a very active triage area and strike team.

Our living accommodations consisted of sleeping outside on a cot with a mosquito net. However, thanks to our logistics staff, we had electricity and fans in the patient treatment areas. Aftershocks were fairly frequent in the first few days after our arrival. The male staff outnumbered the female staff. The bathroom had a sink, which also was used as a urinal. The female staff had a non-flushing toilet that could not withstand any toilet paper in the system without clogging and overflowing. We soon came to the conclusion that a non-flushing toilet was better than no toilet at all.

Soon after arriving we received three young males that were victims of gunshot wounds. These were the first of many penetrating wounds that we would treat over the next few weeks. This was an unofficial orientation for our team to observe the strike team and surgeons in action. One patient went to the OR for an exploratory laparotomy; the second patient decompensated and an emergency thoracotomy/ laparotomy was performed in the ICU. Amazingly, all three of the patients survived.

Triage in an austere environment is difficult at best for an experienced emergency nurse. Most decisions were made based on which patient was most likely to survive. Many of the victims were children. One patient in particular, who everyone in our camp thought was a true miracle, was little Jefferson. Jefferson, a twin, was five days old when he was admitted to our ICU for neonatal sepsis/tetanus. His sister was born first; her cord was cut with a razor at home and the razor was laid down while awaiting Jefferson’s birth. Jefferson’s cord was cut with the contaminated razor, which led to an infected umbilical cord. Upon admission he was lethargic, hypo - thermic and had a low O2 saturation. He was placed in a box for warmth; placed on O2 via cannula; and had two peripheral IV lines placed. During the next few days, Jefferson’s condition went through peaks and valleys, good shifts and bad shifts, and periods of apnea before finally requiring ventilatory assistance to survive. Since we did not have access to a neonatal ventilator on the island, we continued to bag Jefferson until we were able to locate his parents.

I bagged Jefferson for one-and-a half hours until the night shift nurse arrived on duty. We were still unable to locate his parents. One of the night shift physicians continued to ventilate as my shift ended. Later that night, I was told that Jefferson had died, and they had left him with Chaplain Jim to document his death. Jefferson began breathing again without any assistance. I awoke the next morning to find him alive in a night shift nurse’s arms.

Jefferson’s parents arrived later that morning to visit their son. After their visit, they asked the staff to find me. I was still working in the ICU and had just given my report, before going outside to greet the family. They handed me a rosary and their baby. They entrusted their child to me while they left to check on their home. This was one of the most profound memories in my 36-year career as an ED nurse. When I returned to the States, I hung the rosary on the wall above my desk. Every morning when I come to work, I touch the rosary and say a prayer for Jefferson and his family. I will never forget them and baby Jefferson’s recovery.

By the nature of the disaster, the most severe injuries resulted from musculoskeletal trauma. Orthopedic specialists and surgical teams were rapidly deployed to provide life and limb saving care. From January 19 to February 1, they applied 20 external fixators (mostly for femur fractures), and performed 12 amputations and multiple revisions of amputations that occurred before their arrival. Most of the minor procedures were closed reductions and castings of tibial and ankle fractures.

Besides practicing in an austere environment, one of the most challenging parts of patient care was language and communication. Most of the population speak French or French Creole. Each day, young men and women came from the nearby tent city to translate for us. Our safety and security officer developed a program to hire both translators and litter bearers to assist in the operation. This process benefited not only the patients and staff, but also provided temporary employment to the 20 to 30 young people who arrived daily to our compound. Our staff became very creative. Some of the procedures developed were quite novel: boxes lined with foil and used as incubators; foil blankets used as “incubator caves” for infants requiring intensive care and multiple encounters; and boxes cut and designed as wedges to elevate extremities. Meals Ready to Eat (MRE) boxes were multi-purpose and readily available. They were packaged in medium-sized boxes for transport. Once emptied, we collected and stored the boxes under the ICU documentation desk. We used them as bedside trash cans in the unit and also as a barrier for a tetanus patient.

An 18-year-old male was carried into ICU with a severely infected left foot injury. The crush injury occurred two weeks prior to his arrival at GHESKIO Field Hospital. He was anxious and having difficulty breathing. As I began IV catheterization, he satup; looked into my eyes with terror; arched his back and began to seize. I inserted two large bore IVs in his upper arms while one of our physicians obtained an airway. Once stabilized, we maintained his generalized muscle spasms with multiple IV medications. Before my shift was over, he was intubated and placed on a ventilator. He received IV drips of morphine, valium, vecuronium and magnesium sulfate. Plans were in place to amputate his foot later that night. We infiltrated the wound with Tetanus Immune Globulin (TIG), but needed to delay the amputation several hours after administration of the antitoxin due to the risk of releasing tetanospasmin into the bloodstream.

The next morning I arrived in ICU at 7 a.m. This young man had survived the night. Someone had taken one of the MRE boxes and created a head shield for him. We were unable to provide a nonstimulating environment in the ICU due to high activity levels in the unit. This box was placed over the patient’s head to provide a way to decrease stimulation; reduce anxiety; help produce better sedation in coordination with the IV medications; and ultimately relax his muscles.

Tetanus is an illness characterized by an acute onset of hypertonia, painful muscular contractions and generalized muscle spasms. The muscles most commonly involved are those of the jaw and neck. Clostridium tetani is an anaerobic gram-positive bacillus that causes tetanus. These spores can be found in soil, house dust, animal intestines and human feces. Under anaerobic conditions, these spores germinate and produce tetanospasmin. Neurons are affected and become incapable of neurotransmitter release; ultimately resulting in generalized contractions causing tetanic spasm. Patients with generalized tetanus present with trismus (i.e., lockjaw) in 75 percent of cases. This patient was also placed on Penicillin A and metronidazole. By day three, he was able to be transferred to the U.S.N.S. Comfort for a higher level of care.

There are hundreds of stories that each of us has regarding this mission. I was fortunate to be deployed with two of my staff members who work with me in the Emergency Department at Saint Louis University Hospital. Phillis Kessler and Dwight Jones, members of the SLU Hospital DMAT team, also worked long hours to support the patients. They were my rock and inspiration, and I was very proud to share this experience with them. If I had to describe this mission in one sentence: it was emergency nursing at its best!

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